Keeping health records is essential for a smooth learning of an institution. It offers the form of communication between the internal and external stakeholders in the health care environment. Health records can either be in a form of paper documents or electronic data stored in information systems of an organization. Most organizations adopt a hybrid system where data retention, storage, and destruction are handled both manually and through electronic processes. However, health records must be in agreement with the state and federal regulations.
Use of paper forms in a hybrid environment would be a tricky exercise considering that the integrity and security of such information are not guaranteed (McWay & McWay, 2010). The volume of paper forms in a health environment could also be gigantic thus making it difficult to operate manual data storage. It is also worth understanding that papers are prone to significant risks such as misplacement, fire and access to unauthorized persons thus ruining the integrity and security of health records.
Despite the numerous shortcomings, paper recording is unavoidable in health centers. This is particularly intensive in outside correspondences such as consent forms and immunization records where digital records may prove difficult. To deal with the challenges of paperwork in a hybrid system, one can always feed the data to a digital platform soon after data collection. In advanced systems, document imaging could prove vital in ensuring that least of paperwork present in a hybrid model. After feeding paper forms to electronic systems, it is essential to shred the documents to ensure that information privacy is not compromised.
Hybrid records in health environment have both the merits and demerits, and it is the role of the health informatics professionals to make viable decisions on how to utilize it for the best results. One of the primary strengths of the hybrid records is based on the release of information. Hybrid records allow a patient to get printed information from an electronic process. This would be difficult if the information requested is spread over papers and electronic systems (McWay & McWay, 2010). An electronic process can also be coded to ensure faster and efficient retrieval of information on application. It is also prudent to note that hybrid records offer a risk mitigating strategy since it ‘s hard to have paperless record keeping and also helps control large volumes of paperwork.
On the other hand, hybrid records have some weaknesses that health informatics professions must deal with accordingly. One of the major setbacks in hybrid records is the amount of time spent in compiling medical records. One must consider both the paper document and electronic systems while compiling data that could be slow. There are also high chances that human error can lead to incomplete records retrieval. On this note, the integrity of the information is also at stake since it is always difficult to control addendums or updates when files are spread in two systems. It is therefore recommended that health records be in a single system. One should also not forget of the intensive capital requirement for fully functional electronic data storage and processing system.
Legal considerations are also critical in maintaining an efficient hybrid record in a health facility. Health informatics professionals must ensure that the hybrid system is in compliance with privacy and security laws to avoid legal complications (McWay & McWay, 2010). While it is easy to limit access information in an electronic system, it is very difficult to manage the same in the paper documents. This may compromise the privacy and security laws of information handled in papers. Electronic information can also be altered by hackers that can also lead to legal suits. Privacy and security of information are the prevalent legal issues in hybrid records.
Willow Bend Record Policy describes the retention, storage and destruction of health information in paper or electronic media according to the federal laws and other regulations. The hybrid record system at the organization also strives to conform to the provisions of Health Insurance Portability and Accountability Act (HIPAA) and Medicare Conditions of Participation. Medical records must be handled with confidentiality whether in electronic or manual modes. It is worth understanding the Willow Bend hospital guidelines stipulates on guidelines that will ensure highest levels of confidentiality of patients’ records (McWay & McWay, 2010).
For instance, the guidelines as adopted by the hospital are per the state laws. The hospital has maintained health information in accordance to 19.50: Legal Medical Record. This is a provision of the state laws that allows retention of information either manually or through electronic processes. Willow Bend Hospital then converts all paper medical records to electronic format and disposes of the unwanted documents in agreement with the provision of the state laws. It is also worth noting that information retention is also in agreement with the federal legislation of the state (McWay & McWay, 2010). Essential health information such as births and deaths are retained for long periods per the federal laws. The destruction of information is also guided by the federal laws. Willow Bend has also adhered to rules that relate to the use, disclosure, and retention of business records or materials that may be admitted into evidence
Medicare Conditions of Participation are also critical in information retention, storage and destruction in Willow Bend hospital. The conditions require the hospital to provide safe and essential health care to patients. Willow Bend hospital has written a policy that offers the guideline to information storage as required by Medicare conditions of participation. Medical records retention is also in agreement with the Medicare conditions. For instance, information regarding surgical procedure, minors’ medical records, fetal heart monitor records and adult medical records are retained for the expected period in accordance with Medicare conditions of participations.
Health Insurance Portability and Accountability Act (HIPAA) has also been a guideline in the health information retention, storage and destruction of the hospital. The Act has strict provisions that must e followed while dealing with health information. It gives guidelines on to whom and when information should be disclosed. It requires electronic information must be protected from physical and technical hitches. For instance, the hospital feed electronic information via computer output to laser disc into the electronic health information repository system, Apex Patient Folder (APF), without manual intervention (McWay & McWay, 2010).
The information is integrated into permanent repository system to ensure that patients can always get information on request. High levels of confidentiality, as stipulated by HIPPA, are also adopted during the destruction process. The hospital provides that papers are shredded while electronic information is destroyed through overwriting of the disc or physical damage to the disc. The destruction process must be carried out by designated individuals to ensure high levels of confidentiality. It is also important to understand that the hospital maintains a destruction log to keep record of the date of destruction, names of destroyers and method of destruction as well as the patients’ details that is in accordance with the provisions of HIPPA.
McWay, D., & McWay, D. (2010). Legal and ethical aspects of health information management. Clifton Park, NY: Delmar Cengage Learning.
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